- Accurate coding is the standard. Undercoding misrepresents your work as much as overcoding, and a complex panel can justify a high-level distribution when the notes match it.
- Four habits explain most of the gap: default codes, notes that never state the complexity, fear of audit, and never being taught the add-on codes (G2211, prolonged services, ultrasound guidance, modifier 25).
- Fastest wins: stop defaulting to 99213, capture G2211 and modifier 25 when earned, and audit 10 established visits and 10 procedure visits.
- The shape of your code distribution, not the total, shows where documentation is costing you. A spreadsheet works; the online calculator and the Excel tracker do more.
Less clinic, more RVUs
For a stretch I was the busiest person in my department and still losing roughly 20 percent of the work RVUs I had earned, because my notes did not capture what my visits were. When I cut my clinical time to 80 percent and spent the rest on coding and informatics, my annual wRVUs went up: not more patients, not overcoding, accurate coding for the first time.
Undercoding: Why Most Physicians Leave Money on the Table and Don't Know It
- New patient you will see again: code the new-patient visit and add G2211. The pairing credits the ongoing care relationship and is worth more than the visit alone. Wording is in the documentation templates.
- New patient you will not see again, sent for your opinion: an office consultation often pays more than a new-patient visit for commercial payers. Document the request, your opinion, and the report back to the referring physician. See Consultation Codes.
- A procedure plus a real evaluation: inject a joint and also evaluate the problem, and you code both. Show the evaluation stood on its own, or addressed a separate diagnosis, and append modifier 25. Phrasing is in the modifier 25 template.
Why Providers Undercode
Default codes. A comfortable level for the most common visit type, applied broadly: 99213 for the surgeon's post-op follow-up, 99213 or 99214 for the primary care physician's chronic disease session.
Notes that do not match the work. The visit was complex; the note never says so. The coder assigns the lower code, correctly, given what the note says.
Fear of audit. Level 4 gets coded when level 5 is warranted, and level 3 when level 4 is. But a complex specialty or a disproportionately sick panel can legitimately weight a distribution toward level 4 and level 5. The defense is not a lower distribution, it is documentation that matches the complexity.
Unfamiliarity with add-on codes. G2211, prolonged services, ultrasound guidance add-ons, and modifier 25 are real work and real wRVUs, and many providers were never taught they exist.
Where the Gaps Are Most Common
- E/M code level selection for established patients (defaulting to 99213 when 99214 is supported)
- New patient visits coded at 99203 when 99204 or 99205 is supported by the documentation
- Failure to code a modifier 25 E/M when a procedure is performed and a separate evaluation clearly occurred
- Failure to use ultrasound guidance codes when guidance is used
- Missing G2211 for eligible longitudinal care visits
- Fracture care codes coded at the non-manipulation level when manipulation occurred
A Simple Self-Audit
Pull your last 10 established patient E/M visits and count the notes that document two or more chronic conditions actively managed plus a prescription adjusted, then count how many of those you coded 99213. Those were 99214s (the column-by-column check is in Choosing Your Level), and the count is your baseline gap.
Then pull your last 10 visits that included a procedure. For each one without a modifier 25 E/M, read the note: was there a clinical evaluation beyond the procedure itself? If so, that is missed revenue.
That snapshot proves the gap exists. A personal coding dashboard answers the same questions every month, so you know whether it is closing.
Building Your Personal Coding Dashboard: Track Your wRVUs and Find the Gaps
For years my dashboard was an Excel file: my codes, volumes, and wRVUs, updated by hand. Most providers compare the total on their productivity report to their threshold and move on; the distribution of codes in that report is the diagnostic.
What Data You Need
Ask your coding department or practice administrator for a report covering a rolling 3-6 month period:
- Your submitted CPT codes (not just E/M codes, all codes)
- The number of units of each code coded
- The wRVU value associated with each
- If possible, the date of service for each claim
Most EHR and practice management systems can produce it; if not, ask for a raw export of your charges.
What to Look For: The E/M Distribution
Count your established patient 99212s, 99213s, 99214s, and 99215s and calculate the percentage at each level. Compare that to the national benchmark for your specialty: MGMA publishes specialty-specific E/M distributions annually, and your coding department may have those or your payer's own.
If your 99213 percentage is well above benchmark, that is the primary gap. Pull a sample of those notes and run the self-audit on them, with the data choosing the notes; the criteria that separate a 99213 from a 99214 are in Choosing Your Level.
Procedure Code Analysis and the Modifier 25 Check
For procedure heavy specialties, three questions do most of the work.
- In sports medicine, compare 20610 versus 20611. If you use ultrasound routinely and document permanent image storage, your guided injection ratio should reflect that.
- How often does a procedure visit include a modifier 25 E/M? If rarely or never, pull every procedure visit coded without one and read a sample. Each note that documents an evaluation distinct from the procedure decision is missed revenue.
- For fracture care, are manipulation codes coded when manipulation was performed, or are you defaulting to no-manipulation codes?
Tracking Over Time
Track the distribution monthly. After any intervention, whether a template change, a coding education session, or a workflow change, the effect should be visible within 30-60 days.
The Work Is Already Done
You already see the patients, make the decisions, write the notes, and do the procedures. The gap between the credit you get and the credit you earned is a gap in documentation and coding, not in clinical effort. Close it by documenting so the system can recognize the work, then watching your own numbers.
Sources and Further Reading for This Chapter
- HHS Office of Inspector General, evaluation and management coding. https://oig.hhs.gov/
- CMS, Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician